12/1/2014

In my 40 years of involvement as an herbalist in the natural health movement, I’ve seen a panoply of questionable diets, wonder-cures and pseudo-diseases (what herbalist, David Winston calls “disease du jour”) for which there are always ready and willing numbers of experts to vent their theories and assumptions for the many hapless people who think they’ve “got it.” The most recent condition to hit the news is non-celiac gluten sensitivity (NCGS) responsible for the ‘gluten-free’ diet craze, the bane of chefs and cooks everywhere, which has swept the nation.

True celiac disease, which affects anywhere from 1 to 6 percent of the population (depending on the source), is an incurable disease that can only be managed with total abstinence from all glutinous grains such as wheat, rye and barley. Non-celiac gluten sensitivity (NCGS) lies in a grey area depending only on individual subjective complaints, with no reliable medical test to confirm it. Theories and meta-theories abound as to its cause, but essentially gluten sensitivity is a perceived condition largely based on someone’s experience after eating grains and has led many to believe that it is healthier to avoid gluten and especially wheat all together.

Celiac Disease

Celiac disease or genetically based full-blown gluten intolerance has a number of well-recognized symptoms including “depression, ADHD-like behavior, abdominal pain, bloating, diarrhea, constipation, headaches, bone or joint pain, and chronic fatigue” and what may also include a range of possible autoimmune-like reactions.

It is estimated that celiac disease has quadrupled over the last 50 years[i] and according to the National Foundation for Celiac awareness, “95% of people with celiac disease don’t know they have it. This means that foods like bread, bagels, pasta, pretzels, cookies, cakes, and crackers are making them sick -- sometimes VERY sick. Left untreated, celiac disease can lead to further complications such as infertility, osteoporosis, other autoimmune disorders and even cancer.” [ii]

If you suspect that you have gluten sensitivity you should definitely be tested for celiac disease because it can lead to more serious health problems.

Non-Celiac Gluten Sensitivity

But what if you believe you are experiencing adverse symptoms after eating wheat or other glutinous grains and you test negative for celiac disease? NCGS has no biological genetic marker to back it up, and is a condition where individuals claim gluten sensitivity on the basis of experiencing reactions similar to those with celiac disease. What should one do then? Is it really necessary and more healthful to adopt a gluten-free diet in this case?

An astounding $10.5 billion was spent on gluten-free products during 2012 [iii], and this number is expected to reach $15 billion by the end of 2016 [iv]. In an essay published in the Annals of Internal Medicine gastroenterology researchers Antonio di Sabatino MD, and Gino Roberto Corazza MD, of Italy’s University of Pavia stated their evaluation of the benefits of gluten-free eating as hype and said they seek to “prevent a gluten preoccupation from evolving into the conviction that gluten is toxic for most of the population.”

If we side with Drs di Sabatino and Corazza, the gluten-free diet is a limitation that may not be necessary for many to adopt.  Shifting one’s belief from gluten sensitivity as a lifetime stigma to a naturally treatable mal-digestive dysbiotic syndrome may be worth trying. Instead of a lifetime commitment to avoid all glutinous grains, one may only need to undergo a challenge period of no more than six weeks abstaining from glutinous grains, various forms of sugar including some fruit, all dairy and alcohol. The diet during this period should consist of protein, vegetables, probiotics, certain fruits such as berries, heeding common-sense principles of food combining, and including certain herbs to treat digestive problems. After this time, one may find that they are no longer gluten sensitive.

In fact, this is what I and many of my colleagues have found successful for some of our patients who tried abstaining from glutinous grains such as wheat, barley, oats and rye for months with no success.

 

2013 Study Fails to Prove True Gluten Sensitivity 

A 2011 study entitled “Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial”[v] has been widely accepted and cited as proof that gluten sensitivity really exists. But in 2013, after reconsidering aspects of their previous hypothesis, the same group of researchers published a second study apparently disproving their original findings, entitled “No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.” [vi]

The researchers of both contradictory studies include Jessica Biesiekierski and Peter Gibson, the latter being a professor of gastroenterology at Monash University and director of the GI unit at the Alfred Hospital in Melbourne, Australia, and a whole crew of gastroenterology researchers.

The 2013 double-blind, placebo-controlled randomized study involved 37 participants of all ages, all known to be sufferers of irritable bowel syndrome (IBS) and all confirmed to NOT have celiac disease but who felt certain that their health problems were solved adopting a gluten-free diet.

The study’s subjects were first placed on the FODMAP diet, which restricts consumption of fermentable, poorly absorbed, short-chain carbohydrates (fermentable, oligo-, di-, monosaccharides, and polyols [FODMAP; see below]). This diet neutralized symptoms of IBS in the subjects within two weeks.

They were then subjected to a series of double-blind, placebo controlled trials: Some were given a high-gluten diet, others low-gluten, and the rest were given no gluten (control group), using whey protein which was determined to be non-reactive. Subjects on each of the three diets, with or without gluten, reported a worsening of pain, nausea, bloating and gas to similar degrees, all increasing AFTER the two-week symptom-free baseline low-FODMAP diet. Only 8 percent or roughly the equivalent of three of the subjects exhibited symptoms that might be true gluten-sensitivity, while the rest complained of reactions, whether gluten was consumed or not. A second round to the study where subjects were rechallenged with foods containing gluten, whey or no additional protein could not replicate the results. The researchers concluded that “gluten may not be a specific trigger of functional gut symptoms once dietary FODMAPs are reduced.” It may not be the gluten, but some other factors such as the fermented sugar and carbs that was responsible for their IBS. Many gastroenterologists are coming to the conclusion that it may not be the gluten in wheat causing the problems but sugar in the form of fructans[vii] found in the common Western high-FODMAP diet.

What is the Low-FODMAP Diet?

One of the most balanced reports on the latest study appears in an issue published in Science Based Medicine. In it, the author states that “The elimination diet — or the baseline diet — just may be the most important part”[viii] of the study.

‘FODMAP’ is an acronym for “Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.” What these all have in common is that they can be broken down into sugar. FODMAPs ferment and enter the system through the intestines rapidly, thereby causing gastrointestinal symptoms in some individuals. [ix]

The low-FODMAP diet consists of the “dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates” represented by the following foods:

  1. Fructose, or fruit sugar, a fermentable carbohydrate found in vegetables, fruit and honey.
  2. Lactose, or milk sugar, another fermentable carbohydrate. It's found in milk and all dairy products.
  3. Fructans, found in grains, breads, cereals and pasta
  4. Galactans, found in beans and other legumes
  5. Sugar alcohols called polyols, found in certain fruits, such as apples, pears, nectarines, peaches, plums, apricots and cherries.[x]

 

This regime is followed for at least six weeks after which each element is gradually reintroduced in small amounts to determine if there is still any lingering reaction. (Note: In the 2013 study discussed above, the subjects followed this elimination diet for only two weeks.)

Basically, the diet eliminates sugars of all kinds, natural and refined, which are poorly absorbed by the small intestine and proceed to be fermented in the large intestine causing pain, gas and other symptoms. Essentially, we are left with a high-protein, low-carb and low-sugar diet. Vegetables, especially leafy greens, are allowed. A few low-sugar foods including some fruits such as berries and tofu are allowed. Animal protein and all fats are allowed as well. Tofu, lacking the problematical and fermentable fiber makes it possible for vegetarians to undergo this diet as well.[xi] , [xii]

Essentially, FODMAP consumption could be the cause for many who suffer from IBS, gluten sensitivity, Crohn’s disease, candidiasis, Small Intestine Bacterial Overgrowth (SIBO) and Leaky Gut Syndrome (affecting the large intestine).

Could there be a strong psychogenic component to gluten sensitivity?

The subjects in the study above claimed gluten-sensitive reactions even when gluten was not present in their diet. This could be described as a “nocebo effect” – that is, something nonexistent or harmless that causes harmful effects to people who take it.

If the findings of this research are even partially true for a percentage of the over 17 million people[xiii] in the US who presently have given up their favorite glutinous dishes because they think that wheat and glutinous grains may harm them, then a belief system shift may be all that is needed to help them. Some who experience adverse symptoms when they eat gluten can manage and eliminate these symptoms with diet and herbs, resulting in improved digestion and overall wellness.

A Different Take on NCGS: Dysbiosis

Just to make things more confusing, Consumer Reports has published a report listing a number of reasons why gluten-free may not be the healthiest alternative and that gluten “may actually be good for you.”[xiv] Citing a small preliminary study that among other things suggests that gluten protein has a beneficial effect on triglycerides and may even help blood pressure, they mention how even the fructans starches in wheat, limiting of which is important in the FODMAP diet for IBS patients, supports healthy intestinal bacteria, including Bifidobacterium, B. longum and lactobacillus in the digestive system.[xv]

I think there is another way of looking at and managing the dilemma: For the many who complain of gluten sensitivity, their problems may not specifically be caused by gluten, but are part of wider digestive imbalances traditionally treated with digestive bitters, fermented foods and other herbal approaches. The condition called dysbiosis, which refers to the imbalance of beneficial bacteria in the body and their ability to check each other’s populations and manage waste, was first recognized in Western medicine in 1908 by Dr. Elie Metchnikoff, director of the Pasteur Institute, who was awarded a Nobel Prize for his work describing the link between the immune system and intestinal flora.[xvi] Dysbiosis in its many variations and forms seem to be implicated in the majority of GI disease syndromes of recent decades.

I propose a simple strategy of limiting sugar and carbs, somewhat similar to the highly restrictive FODMAP diet and, following the lead of its exponents, following this for only a six-week period.  During this time and after, traditional herbs and formulas should be included to promote digestion and reduce the overpopulated bacteria. In terms of Ayurvedic theory, this strategy seeks to kindle ‘agni’ (digestive fire); in terms of Traditional Chinese Medicine (TCM), it aims to ‘invigorate Yang and regulate and boost Spleen Qi.”

Next week I will present herbs and formulas for this proposed approach as well as share my own clinical findings.


 

[i] http://preview.ncbi.nlm.nih.gov/pmc/articles/PMC2704247/

[ii] http://www.celiaccentral.org/Gluten-Free-Food/the-gluten-free-diet/

[iii] Ibid – Mintel, a market research company.

[iv] http://www.buzzworthy.com/science-proves-gluten-sensitivity-isnt-real-people-are-just-whiners/

[v] http://www.ncbi.nlm.nih.gov/pubmed/21224837

[vi] http://www.ncbi.nlm.nih.gov/pubmed/23648697

[vii]http://www.npr.org/blogs/thesalt/2014/05/22/314287321/sensitive-to-gluten-a-carb-in-wheat-may-be-the-real-culprit

[viii] http://www.sciencebasedmedicine.org/a-balanced-look-at-gluten-sensitivity/

[ix]http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/Parrish_Dec_12.pdf

[x] http://www.livestrong.com/article/507667-what-are-fermentable-carbohydrates/

[xi] http://www.quickanddirtytips.com/health-fitness/healthy-eating/ask-the-diva/fodmap-diet-why-is-tofu-allowed-but-soybeans-arent?page=all

[xii] http://www.ibsfree.net/news/2014/5/18/fodmaps-and-soy-why-so-confusing

[xiii] http://www.nytimes.com/2014/02/18/business/food-industry-wagers-big-on-gluten-free.html?_r=5

[xiv] http://www.consumerreports.org/cro/magazine/2015/01/will-a-gluten-free-diet-really-make-you-healthier/index.htm

[xv] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3023594/

[xvi] http://www.aloeride.com/aloe-vera/candida-overgrowth-and-aloeride-extra-strong-aloe-vera/

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